This article considers how the recently updated HTM 03-01 can be a catalyst for continuous operational improvements and service transformation. When supported with a ‘smart logbook’, Authorised Persons (Ventilation) can play an increasingly important role in informing their Trust’s Ventilation Safety Group (VSG), while effectively discharging their responsibilities for the practical implementation and operation of management’s safety policy and procedures. A smart logbook increases the transparency of verification data, and improves overall situational awareness. If coupled with innovative management practices, this will also support team learning to build shared visions and a strong positive organisational culture which, in turn, enables every VSG to play a key role in optimising theatre availability
Our healthcare system is under increasing pressure, and it is essential that the availability of scarce resources such as operating theatres is optimised. Traditionally, experienced professionals have provided expert guidance to ensure that assets and service capacity are adequate to support demands. However, with rapidly advancing technology, and as more and more data becomes available, innovative systems-based processes will improve the management of resource availability.
HTM 03-01 provides an excellent platform to transform workflows and ensure the optimum availability of ventilation systems when coupled with Systems Thinking and smart logbooks
Ventilation data
Data is essential for effective management. There must be sufficient data, and it must be suitably structured so that it can be processed effectively. Once analysed, the resulting information must be presented clearly so users have good visibility of actionable insights and can deliver effectively.
HTM general guidance
As all healthcare estates management and healthcare engineering personnel will know, the Healthcare Technical Memoranda establish a clear framework for the collection and use of data:
HTMs give comprehensive advice and guidance on the design, installation, and operation, of specialised building and engineering technology used in the delivery of healthcare.
The focus of Health Technical Memorandum guidance remains on healthcare-specific elements of standards, policies, and up-to-date established best practice. The HTMs are applicable to new and existing sites, and are for use at various stages during the whole building lifecycle.
Healthcare providers have a duty of care to ensure that appropriate governance arrangements are in place, and are managed effectively. The Health Technical Memorandum series provides best practice engineering standards and policy to enable management of this duty of care
HTM 00 and risk
HTM 00: Polices and principles of healthcare engineering1 explains the need to minimise risk, and highlights the need to establish principles and procedures which reflect the important role that engineering policies and principles, as implemented by suitably qualified professional and technical staff, have in support of direct patient care
HTM 03-01: Specialised ventilation for healthcare buildings2 is the most recently updated HTM. Section 13 of Part A details the different types of information required to design, install, verify, and maintain, ventilation systems in accordance with the requirement under the Building Regulations. It is essential to provide documentary evidence of the design, commissioning, and subsequent performance of ventilation systems, as well as recommended maintenance routines (Building Regulations. 2010, Part 8, Paragraph 39).
One of the key obligations under HTM 03-01 Part A, 13.15, is for the provision of a logbook for each system, which evidences the full operational history, and which – if established correctly – can be a rich source of data for all the designated staff.
Asset lifecycle management
Under HTM 03-01, the air-handling unit (AHU) in a ventilation system is expected to have an operational life of 20 years. Currently, it is estimated that a large proportion of NHS theatre ventilation systems are in the latter stages of their lifecycle – in some cases, AHUs may already be operating beyond their expected life. It is also worth noting that as PFI contracts come to an end, even more ventilation systems will be passed back to the NHS, and it is inevitable that some of them will continue to be used. Wherever assets are reaching, or have passed the end of, their useful life, it is vitally important to maintain full data on these higher-risk assets, even though they might be about to be replaced.
Verification and scrutiny
Annual verifications provide a vital source of information about the operation of ventilation systems. Carried out by independent engineers, these annual checks provide essential evidence on both condition and performance. Appendices 1 and 2 of HTM 03-01 Part B identify a minimum set of data to be collected annually, or more frequently if required, to reflect any inherent risk associated with older equipment
The checks specified to assemble the minimum dataset relate to specific assets, sub-assets, and rooms, which are characterised by their position in the cleanliness hierarchy. However, that underlying structure is not entirely obvious from the sequencing of the checklists, and those checks are not weighted for risk, so analysis by simple scoring may not represent the operational situation accurately. Also, each verifying engineer has their own individual style of reporting: generally, their reports are extensive (often 20 pages or more), and the underlying unstructured data can be difficult to understand, evaluate, and benchmark.
The Invigilatis Seeker Ventilation Logbook structures verification data, so it can be analysed easily, and presented effectively, for users to have a holistic view of a hospital’s theatre suites and critical systems, along with the historic performance trends. With consistent and well-structured data, the full potential of technology can be exploited, and the annual verification used to confirm system compliance and provide maintenance alerts
Analytics and presentation
By applying analytical rules consistently, the extensive data from series of annual verifications can then be presented clearly, so users have meaningful information. ‘Smarts’ will aid analysis and presentation, and rankings and comparisons will allow trends and context to be established easily and promptly. Considerable efficiencies/ time savings will be achieved from having better information.
It is important to note that the annual ventilation verification information and data is not used exclusively by engineers and Estates teams; it is also relevant to Infection Prevention teams and theatre managers. It is thus concerning to note that a leading surgeon who has considerable experience of ventilation issues – Hilary Humphreys – recently wrote that ‘Infection prevention and control team members (IPCTM) are often intimidated by aspects of ventilation as they relate to healthcare, because they consider them technical and outside their area of comfort and expertise. However, engineers, Estates departments, and planners need IPCTM input to ensure appropriate design and use’.3 With effective presentation of information derived from verifications, Estates can provide safe systems, Infection Control can minimise risk, and theatre managers can optimise revenue flows.
Smart logbooks, VSGs, and quality improvements
Traditionally, paper logs were available for every critical system, and the associated recording processes were routine, so the logs only contained a limited amount of information. Technology enables a wealth of data to be aggregated easily but, to date, it can be argued that technology has both improved and worsened the traditional situation. It may have improved the collection of and access to some data, but masses of incomplete data does not necessarily improve the quality of the information available to support the associated management processes.
However, a smart log book such as Seeker Ventilation can provide a golden source of verification data which informs the designated staff and other users, who may have different lines of reporting and individual goals. Whether simple rules-based AI or more sophisticated technologies, ‘smarts’ can aid analysis and presentation of that information. By identifying data gaps and missed deadlines, the smart logbook improves the efficiency of data management, which enables a Trust’s overarching holistic goals to be achieved with minimal effort, saving considerable operational time.
Responsibilities and remit
While the practical implementation and operation of management’s safety policy and procedures relating to the engineering aspects of ventilation systems are the responsibility of the Authorised Person (Ventilation) (AP(V)), the management of the healthcare provider’s ventilation systems is overseen by a Ventilation Safety Group (VSG), which should:
have clearly defined roles and responsibilities covering all aspects of the ventilation systems’ lifecycle – plan, acquire, use, maintain, and dispose.
be part of a healthcare organisation’s governance structure, and report to the ‘Designated Person’ at Board level.
Decisions affecting the resilience, safety, and integrity of the ventilation systems and associated equipment should be taken with the agreement of the VSG. Major investment decisions require considerable amounts of information, but the associated decision-making processes can often be straightforward. In contrast, with increasing pressure to optimise the availability of resourcing, management processes need to be established to support the continuous programme of decision making based on the flows of verification information, its analysis, and the resulting performance rankings.
‘Improved transparency’
The improved transparency available from a smart logbook such as Seeker Ventilation will facilitate communication, and enable AP(V)s to support all members of their VSG to operate effectively. By adopting relatively simple techniques based on better flows of information, VSGs can also deliver the incremental performance improvements which are expected in today’s goal-orientated operations, and can ensure essential marginal gains in theatre availability.
Parallels for the introduction of continuous improvement can be found in other areas of healthcare: e.g. a system–centred risk management model for primary care organisations which had a major impact on risk. Sharing of risk information in an easily digested format by clinicians and administrators saw a 90% risk reduction achieved in the repeat prescription of medicines. The risk management model was based on systems thinking, and in particular Edwards Deming’s iterative four stage PDSA (Plan Do Study Act) management method,4 which is used extensively in business for the control and continuous improvement of processes and products. In order to achieve improvements, outcomes are monitored and then reviewed so that processes can be revised to enhance performance even further
Systems thinking – optimising the delivery of better ventilation outcomes
Systems thinking is a holistic approach to problem-solving. It is often used to develop effective actions for complex situations, and it focuses on both how a system’s constituent parts inter-relate, and how that system works within the context of larger systems. Deming’s PDSA cycle is a proven example of Systems Thinking which enables continuous quality improvement processes. It is an ideal approach for VSGs to adopt to deliver better ventilation outcomes.
PDSA process
Informed by verification data, the PDSA process can be introduced to drive continuous improvement. Information derived from the analysis of the verification data can immediately support the study step of the process for an abbreviated initial cycle, which then informs the actions, and allows a plan to be established for the ongoing improvement cycles. With suitable engagement by all concerned, this continuous quality improvement process will have positive outcomes which impact directly on the Trust’s performance, and thus result in increased theatre availability and revenue.
Organisational culture
While the PDSA improvement process can be established easily, its success is entirely dependent on the organisation’s culture. Deming realised this, and proposed his System of Profound Knowledge (SPoK), which provides a highly integrated framework for the cultural transformation needed to support continuous improvement. Beginning with transformation of the individual, SPoK will ensure that managers become leaders, and also ensure that people in those organisations continually improve, with the aim of everybody winning. His book, The New Economics for Industry, Government, Education, 5 presents a detailed explanation of his SPoK. It echoes the work of Peter Senge, who also emphasised the need for building a shared vision, and team learning ,which was summarise in his book, The Learning Organisation. 6 With an associated cultural shift, teams can progress from simply reacting to the present issues, and become focused on delivering continuous improvement to create the better future outcomes.
Systems thinking is becoming more widely adopted in healthcare, and it forms the basis of several similar management techniques, such as Kaizen and Six Sigma. They each have slightly different terminologies and focus, but they all require cohesion and learning.
There is already good NHS support for these smarter ways of working through NHS Elect, which provides leadership and organisation development programmes to Trusts. Collaborative support is also available from the NHS National Performance Advisory Group. Its Operating Theatre Best Value Group shares information, and provides insights, to assist with daily activities, and strives for continuous service improvement
Conclusions
While not specifically written about data and the rapidly changing world, HTM 03-01 outlines the functional responsibilities of designated staff, and the data to be collected during verification, and provides a sound platform to establish procedures which support resource optimisation.
Smart logbooks such as Seeker Ventilation improve the visibility of verification information. This enables AP(V)s to improve their control of maintenance and the flow of information to their VSG, both of which can lead to higher levels of theatre availability. However, when that smart collaborative technology is also coupled with the innovative management practices which deliver continuous quality improvement, every VSG can lead improvements in their Trust’s management of ventilation systems, and optimise their availability
Stephen Bartlett
Stephen Bartlett is an information professional with considerable experience of resource planning, risk management, and healthcare estates management. Having qualified as a Chartered Accountant and, after a spell as Finance director of a database publisher, he then worked with central government to establish some of the initial Internet infrastructure needed for departments to ‘begin their shift from paper’. With a strong focus on knowledge management, this work included establishing taxonomies and real-time services providing immediate access to essential information.
Subsequently he was Deputy Chairman of a provider of resource scheduling software, before joining Invigilatis as CEO, and leading its evolution into ‘a leading provider of compliance solutions for healthcare and complex healthcare estates’. He ensures that compliance solutions enable both the compliance performance achievement to be viewed easily, and the underlying non-compliances to be understood. Invigilatis’ solutions ‘empower managers while supporting collaborative management processes’. The company says that its most successful solution resulted in a 90% reduction in risk.
References
1 HTM 00: Polices and principles of healthcare engineering. Department of Health, 2014.
2 HTM 03-01: Specialised ventilation for healthcare buildings. Department of Health and Social Care 2022
3 Humphreys H. Infection prevention and control considerations regarding ventilation in acute hospitals Infect Prev Pract 2021 Oct 20; 3(4):100180.
4 R Moen: Foundation and History of PDSA Cycle; 2009. https://tinyurl.com/yeyshjeb
5 Edwards Deming W. The New Economics. 1993.
6 Senge P. The Learning Organisation. 1990